Fat/Fascia during TEPP Mesh Hernioplasty for Inguinal Herniaâ) is my own ..... to perform the TEPP hernioplasty with ease, rapidity and safety for the lasting cure.
A Study of Laparoscopic Surgical Anatomy of Infraumbilical Posterior Rectus Sheath, Fascia Transversalis & Pre-Peritoneal Fat/ Fascia during TEPP Mesh Hernioplasty for Inguinal Hernia
A Thesis Submitted for the award of the Degree of DOCTOR OF PHILOSOPHY In SURGERY By DR. MAULANA MOHAMMED ANSARI MBBS, MS (Surgery) Department of Surgery Faculty of Medicine, Jawaharlal Nehru Medical College Aligarh Muslim University, Aligarh – 202002, UP, INDIA
May, 2016
Credentials, Abstract, List of Tables/Figures
CANDIDATE’S DECLARATION I, Dr. Maulana Mohammed Ansari, Department of Surgery certify that the work embodied in this Ph.D thesis (titled -“A Study of Laparoscopic Surgical Anatomy of Infraumbilical Posterior Rectus Sheath, Fascia Transversalis & Pre-Peritoneal Fat/Fascia during TEPP Mesh Hernioplasty for Inguinal Hernia”) is my own bonafide work carried out by under the supervision of ‘Self-Supplication’ and the co-supervision of ‘Self-Supplication’ as a ‘Teacher Candidate’ at Aligarh Muslim University, Aligarh. The matter embodied in this thesis has not been submitted in part or full to any University or Institution for the award of any Degree or Diploma. I hereby declare that I have faithfully acknowledged, given credit to and referred to the research workers wherever their works have been cited in the text and body of the thesis. I further certify that I have not willfully lifted up some other’s work, para, data, result, etc. reported in the journals, books, magazines, reports, dissertations, theses, etc., or available at web-sites and included then in this Ph.D. thesis and cited as my own work.
(Dr. Maulana Mohammed Ansari) MBBS, MS (Surgery) Department of Surgery, J. N. Medical College, Aligarh Muslim University, Aligarh, UP, India
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DEPARTMENT OF SURGERY J. N. MEDICAL COLLEGE, FACULTY OF MEDICINE ALIGARH MUSLIM UNIVERSITY, ALIGARH
Certificate It is hereby certified that Dr. Maulana Mohammed Ansari is working as Professor of General Surgery in the Department of Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, UP, India. The research work in this Ph.D. thesis entitled - “A Study of Laparoscopic Surgical Anatomy of Infraumbilical Posterior Rectus Sheath, Fascia Transversalis & Pre-Peritoneal Fat/Fascia during TEPP Mesh Hernioplasty for Inguinal Hernia” has been carried out by Dr. Maulana Mohammed Ansari himself with full dedication and sincerity. His self-supplication of this research work without a supervisor/co-supervisor has been duly approved by the Board of Studies of the Department of Surgery, the Institutional Ethics Committee and the Committee of Advanced Studies and Research (CASR) of the Faculty of Medicine, Aligarh Muslim University, Aligarh.
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DEDICATION
iv
Table of Contents Page No. Acknowledgements
vi - ix
Abbreviations
x
Abstract
xi - xv
List of Tables
xvi
List of Figures
xvii - xx
Chapter – I: Introduction, Contemporary Issues & Present Strategy 01-10 Chapter – II: Review of Literature
11-58
Chapter – III: Clinical Research Methodology
59-72
Chapter – IV: Observations & Results
73-212
Chapter – V: Discussion Chapter – VI: Summary of Thesis
213-256 257-272
Chapter – VII: Outlook & Scope for Future Research References (Alphabetical Order)
273-294 295-312
Annexures:
313 -
o o o o o o o
Annexure I: Annexure II: Annexure III: Annexure IV: Annexure V: Annexure VI: Annexure VII:
Ethical Clearance & CASR Approval Informed Consent Form Proforma For Data Collection Working Papers (List) Published Papers (List & Full Texts) Profile of the Candidate Soft/Digital Material (List, Videos, & PDFs) List of Video Clips (Eleven in Number) Thesis-Related Publications (6 ) Complete Bio-Data of the Candidate
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ACKNOWLEDGEMENTS The prophetic saying of ‘He who is not thankful to other fellow beings is also not grateful to The Almighty’ is true in both spirit and letters (Tirmidhi). Thus, heartfelt acknowledgement beyond the ‘auto pilot thanksgiving’ is a small but extremely important way of reconnecting with people beyond tweets and texts, and deepening our resolve in the accurate scientific learning and logic, a reflection of The Almighty. First and foremost, I am deeply grateful to The Almighty who imparted to me knowledge through my loving parents and surgical science through my excellent teachers, and who provided me this golden opportunity in bringing out one of the best aspects of myself into the print in the form of a PhD thesis for submission in this great institution of Aligarh Muslim University. Undoubtedly, nothing is possible without the Grace of the Almighty. Verily competence alone is not sufficient. It always needs an intellectual inspiration and motivation to sail in an unchartered territory of the surgical science. I always felt a deep sense of appreciation to (late) Prof. Masood Ashraf, the former chairman of the department who was instrumental in 1998 for my laparoscopic training at the Maulana Azad Medical College, New Delhi under the proficient guidance of Prof. Ravi Kant who is presently the Vice-Chancellor of King George Medical University, Lucknow, and thereafter for establishing the laparoscopic surgery (cholecystectomy) by the undersigned at our institution in 1999, using the single chip camera and refurbished equipment and instruments arranged by an alumnus of the University, Dr. Khursheed Mallick, a renowned Urologist based in Chicago. I feel obliged to recall one of our brilliant students, Dr Mohammad Atif for implanting in me the idea of a clinical research on the live surgical anatomy. However, the main credit goes to another brilliant student and later a junior colleague of mine, Dr. Abdul Hai, Assistant Professor of Surgery, who really motivated rather coaxed me to start the TEPP hernioplasty without first learning the TAPP approach. Wow, the first 40 successful TEPPs without conversion or complication made the undersigned repent why the procedure was not started by the undersigned earlier. This thesis is a product of the unwavering support of my parents, my wife, my three sons & daughter, friends and colleagues. I am deeply indebted to my mother, (Late) Mrs. Mofidun Nisan, and my father, (Late) Mr. Haji Ghulam Jilani, for developing a down-to-earth integral personality and aptitude by thorough preparation & constant hard work. I am also profusely indebted to my mother-in-law, (Late) Mrs. Zubaida Haleem and father-in-law, Dr. Abdul Haleem, MD (Medicine, 1962), for being a role model in terms of rock-solid willpower, exemplary inspirational skill, high aims and visions in academic career and life. In particular I would like express my profound respect, gratitude and indebtedness to my loving wife Prof Shahla Haleem for her endless
Acknowledgements
encouragement and stellar supports throughout my academic journey. I am profusely grateful to my son Ahmad Omar, B.Tech, M.Tech (IIT, Chennai), PhD (IFW, Germany), who diligently made all the computer-generated illustrations, and who also contributed a lot during the final drafting and proof reading of the present thesis. Lot of credit goes to my daughter Rubeena, B.Tech, MS (UWO, Canada) who carried out the final proof reading of the observations and discussion, and picked up some glaring mistakes for correction, saving my face. So is the case with my son Ahmad Ovais, B.Tech, MBA (UT, Canada), especially in finalizing the abstract and summary of the thesis. Oh, the rather computer-illiterate father could not have carried out the thesis work on the laptop unless the youngest son Ahmad Ozair, I.Sc, has kept on sorting out the computer glitches every now and then. His inputs into the chapter outlook and scope for future research were also invaluable and scintillating. It is also a matter of immense pleasure to express my sincere thanks to my brother-in-law, Prof. Abid Haleem, PhD (IIT, Delhi), Former Director of Internal Quality Assessment Cell, and Professor of Mechanical Engineering, Jamia Millia Islamia, New Delhi for his strong moral support and precious suggestions in making this thesis adhere to the global standard of a doctoral research. Heartfelt thanks also go to Dr. Sarfraz Ahmad, PhD, FABAP, FACB, Professor and Director of Clinical Research, University of Central Florida, Florida, USA for his invaluable suggestions and help. I would like to thank all my senior and junior colleagues of the Department of Surgery for allowing and helping me in choosing and executing this novel first-of-its-kind project of the doctoral research in the department. Special thanks go to Prof. Mohammed Habib Raza, the former chairman of the Department of Surgery, who was a constant source of encouragement and who arranged additional laparoscopic equipments and instruments with a lot of his personal efforts. He always made a point to regularly come inside the operation room during the on-going procedure of the TEPP hernioplasty to hearten our spirit and confidence. I will never forget his sincere efforts to a have a thrust for the advanced laparoscopic surgery at our institution and to take the department to the high vision of 2020. I am also deeply thankful to the present chairman of the Department of Surgery, Prof. Mohammad Aslam, MS (Surgery), DNB, FRCSEd (A), MNAMS, FMAS, who maintained the legacy of inspiration and constant support in completing the present research. Special thanks also go to the senior member of the department of Surgery, Prof. M Amanullah, FICS, for his lively discussion and support. My heartfelt appreciation also goes to (late) Prof. Akshay Kumar Verma who often stooped down to bring junior colleagues like myself into the intraoperative discussion and often accepting our vii
Acknowledgements
opinion for the definitive surgical procedure, a legacy worthy to follow. I can never forget the golden opportunity to serve the University when (Late) Prof. Naseem Ansari, the former chairman of the department of Surgery sanctioned in 1987 my appointment as the Clinical Registrar (General Surgery) and promoted me to the coveted post of Lecturer (General Surgery) in 1989. With a deep sense of gratitude, I convey my sincere thanks to Prof. Jamal Ahmad, the Dean, Faculty of Medicine, Aligarh Muslim University, Aligarh and Prof Tariq Mansoor, Principal-cumChief Medical Superintendent of J. N. Medical College & Hospital, for their constant encouragement, support and focused attention towards academics and research. The tireless work and continuous care provided to the patients recruited in the present study by the surgical residents is really praiseworthy. Special thanks also go to the residents which helped the undersigned in collection and documentation of the patients’ data, especially Dr. Sarfraz Ahmad, Dr. Meraj Ahmad, Dr. Vibhor Pateria, and Dr. Amanjee Bharti. Dr. Mohammad Wasif Ali, Assistant Professor and Dr. Tausif Ahmad, Senior Resident also deserve a lot of credit for their wonderful assistance during the execution of the TEPP hernioplasty.
Presence of the young
surgeons, Dr. Sadik Akhtar and Dr. Manzoor Ahmad, inside the Operation Room was always a source of encouragement and pleasure. I also thank Mr. Abdul Haleem, a PhD scholar (Statistics), for helping me in the statistical analysis. I am truly indebted to the all the anaesthesiologists in general and Prof Shahla Haleem in particular for the excellent conduct of the relaxant general anaesthesia, making the smooth execution of the TEPP hernioplasty easily possible. I express my sincere thanks to the technical staff of the Surgery Operation Theatre, especially Mr. Mohammad Baqaullah, Sister Nisar Ahmad and Sister Iffat Afzal who worked tirelessly for the conduct of the laparoscopic surgery, especially the TEPP hernioplasty, and always bore the brunt of our surgical stress and strain nonchalantly. All credit goes to their calm and quiet attitude that made all the difference in completing the huge task of an unhurried laparoscopic hernioplasty with full demonstration for the sake of collective wisdom in identification of the tissue planes and judicious surgical dissection. Special thanks also go to Mr. Noorul Ahad and Sister Tabassum for providing additional logistical support in the operation theatre premises. The nursing staffs of the surgical wards also deserve full credit in caring for the patients recruited in the present study. It is also my pleasure to thank the non-teaching staff of the Department of Surgery, especially Mr. Abid Husain, Mr. Aziz Ahmad, Mr. Mohd. Muqeem, Mr. Tanvir Ahmad, Mr. Javed Akhtar, Mr. Salim Naseem, Mr. Dinesh Singh Negi and Mr. Gopal Krishna for their logistical help and cooperation at every step of the thesis related work. I thank Mr.
viii
Acknowledgements
Amanullah, S.O. in the Office of the Dean for his invaluable assistance in the administrative matters of the PhD programme of the University. I again express my sincerest thanks and deepest gratitude to my whole family for their unflagging love, encouragement, efforts, sacrifices, healthy criticism, etc., etc. Finally I humbly seek further Guidance and Benevolence of The Almighty and pray to Him for developing the state-of-the-Art health care facility in our medical college for the larger good of the masses and for mounting the focused research work towards the global recognition to our beloved University. The Aligarh Muslim University, Aligarh has immensely contributed to my career and life. I am truly indebted to this great seat of higher learning and training. Last but not the least I must thank all my patients who readily allowed me for an invasive procedure of newer technology into the private parts of their body.
May 2016
Maulana Mohammed Ansari JNMC, AMU, Aligarh
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LIST OF ABBREVIATIONS Abbreviation
Full Term
Abbreviation
Full Term
TEPP
Total extra-peritoneal preperitoneal
AL
TAPP
Transabdominal preperitoneal
SWD
PRS IC-PRS C-PRS NIC LIC SIC WT MT
Posterior rectus sheath Incomplete PRS Complete PRS Normal Length Incomplete PRS Long Length Incomplete PRS Short Length Incomplete PRS Whole Tendinous PRS Musculo-Tendinous PRS Partly Tendinous PRS (Superiorly Tendinous and inferiorly attenuated)
SID DAL A NS-SWD H-SWD L-SWD NS-SID L-SID
Arcuate line single sharp well defined AL Single Ill-Defined AL Double/Multiple AL Absent Normal-Sited SWD High SWD Low SWD Normal-sited SID Low SID
U - AL
Umbilicus to Arcuate Line
TO
Thinned Out Throughout PRS
Z – AL
GA
Grossly Attenuated PRS Classical Normal Length Whole Tendinous PRS
Z-U
V-PRS
Variant PRS
AL - PS
SWT
Short Whole Tendinous PRS
AL - ASIS
LWT CWT CMT
Long Whole Tendinous PRS Complete Whole Tendinous PRS Complete Musculo-Tendinous PRS Classical Normal Length Partly Tendinous PRS
TF FL SM
Xiphisternum to Arcuate Line Xiphisternum to Umbilicus Umbilicus to Pubic Symphysis Arcuate Line to Pubic Symphysis Arcuate Line to Interspinous Line Transversalis fascia Thin Flimsy Single Membranous
SD
Single Diaphanous
LPT
Long Partly Tendinous PRS
SLEXT
CPT
Complete Partly Tendinous PRS
ILEXT
NTO CTO NGA CGA RA RF
Normal Length Thinned Out PRS Complete Thinned Out PRS Normal Length Grossly Attenuated PRS Complete Grossly Attenuated PRS Rectus Abdominis Rectusial Fascia
IFL TFS MEXT PF IPT TA
CID
Confidence Interval of Difference
TAA
CHISQ CC SD WD ILD P V D CL CM EPF MIF
Chi Square Correlation Standard Deviation Well-Defined Ill-Defined Present Deep Inferior Epigastric Vessels Vas Deferens Cooper’s Ligament Corona Mortis Preperitoneal Fat Minimally Fatty EPF
N-TAA V-TAA H-TAA L-TAA VL-TAA A-TAA PPF DM ISF MOF EXF
PT
NWT
NPT
U - PS
Superior Lateral Fascial Extension Inferior Lateral Fascial Extension Interfoveolar Ligament Transversalis Facial Sling Medial Fascial Extension Pectineal Fascia Ilio-Pubic Tract Transversus Abdominis Transversus Aponeurotic Arch Classical Normal TAA Variant TAA High TAA Low TAA Very Low TAA Absent TAA Preperitoneal Fascia Double Membranous Internal Spermatic Fascia Moderately Fatty EPF Excessively Fatty EPF
ABSTRACT Background: Contrary to the general belief, extraperitoneal anatomy of the groin is reported to be complex, and is often not properly understood by majority of the practicing surgeons, leading to difficulties in performing the laparoscopic preperitoneal repair of the inguinal hernia, especially in presence of the anatomic variations reported by several investigators over the last several decades, which have received little/no attention of the anatomists & the practicing surgeons alike. Most studies are based on the gross anatomic dissections. Studies on the live surgical anatomy during laparoscopic hernioplasty are scarce and sparsely reported in literature and hence present study. Objective and Aims: To perform the laparoscopic total extra-peritoneal preperitoneal hernioplasty (TEPP) for inguinal hernia and to study the morphology of the posterior rectus sheath, arcuate line, pre-peritoneal fat/fascia and transversalis fascia below umbilicus during the TEPP hernioplasty. Research Methodology: After approval, TEPP hernioplasty was performed under the written informed consent of the patient (Fig. 1). The standard 3-midline-port technique was adopted, utilizing direct telescopic dissection in most of the cases under CO2 insufflation pressure of 12 mmHg. Instant data collection and documentation were done along with video recording as and when digital video recorder was available. Patients were followed for a period of 5 to 61 months after discharge from the hospital. Statistical analysis was done by the SPSS software (v. 21) mainly. Results: A total of 63 patients with uncomplicated primary inguinal hernia (unilateral 54; bilateral 9) were taken up for TEPP hernioplasty. Three patients required early conversion and were excluded from the study. The remaining 60 patients underwent TEPP hernioplasty successfully for 52 unilateral hernias (left side 35; right side 17) and 8 bilateral hernias, and thus, the analysis of data was carried for a total of 68 TEPP hernioplasties (Unilateral TEPP 52; Simultaneous Bilateral TEPP 5; Interval Bilateral TEPP 3) which formed the body of the present study. The results are herein presented in the format of mean ± standard deviation unless specified otherwise. All patients were male, with an overall mean age and BMI of 50.1±17.2 years (range 18-80) and. 22.6±2.0 kg/m2 (range 19.3-31.2) respectively. Ratio of ASA grade I: II was 4.5: 1. Variations were observed in all the primary outcome measures of anatomic structures in a high percentage of cases. A total of 12 morphological types of posterior rectus sheath were observed, with classical anatomy in 46% of cases and variant anatomy in the remaining 54%. Non-mirror anatomy of the PRS was observed on the two sides of the body in 75% of the bilateral hernias. A total of 7 morphological types of arcuate line (inferior border of posterior rectus sheath) were recorded, with classical arcuate line in 46% of the cases and variant arcuate line in the remaining 54%. Non-mirror anatomy
Abstract
of the AL was observed on the two sides of the body in 62.5% of the bilateral hernias. In the suprainguinal region, the transversalis fascia was found as a well-defined single membranous layer (72%) and thinned-out flimsy layer (28%). However, in the inguinal region, transversalis fascia was of three types – single diaphanous layer (60%), single membranous layer (15%) and thinned-out flimsy layer (25%). Preperitoneal fascia was observed in all cases - as a definite single membranous layer in 82% of the cases, and as a double membranous layer in the remaining 18%. Preperitoneal fat in the present study was minimally fatty in 56%, moderately fatty in 34%, and excessively fatty in 10% of the cases. The anatomy of the transversalis fascia, preperitoneal fascia and preperitoneal fat was a mirror image on the two sides of the body in all cases of bilateral hernias. Wide variations were also recorded in the different analogs of these anatomic structures. The variant anatomy of the posterior rectus sheath, arcuate line, transversalis fascia and preperitoneal fascia adversely affected the secondary outcome measures of endoscopic vision, ease of procedure, operation time, peritoneal injury and surgical emphysema. However, the postoperative seroma, infection and chronic pain were not affected by the presence of the anatomic variations. Conversion secondary to anatomic variation was seen in 1.6% of the cases. Variations in the preperitoneal fat did not affect any of the secondary outcome measures. There was no recurrence of hernia in the mean follow up period of 33 ± sd 17 months (range 5-61 months). A well-defined ‘rectusial fascia’ was also seen consistently in all patients, which represented a fascial condensation/ thickening in epimysium of rectus abdominis muscle, along with a ‘retropubic fascia’ as its extension analog. Internal spermatic fascia was found consistently as an extension analog of preperitoneal fascia in all cases, along with a secondary internal inguinal ring. Cord Lipoma was present in 16% of cases and was observed as an extension analog of preperitoneal fat. In a nut shell, incidence of the individual variant anatomy in the 4 major structures studied, namely, posterior rectus sheath, arcuate line, transversalis fascia and preperitoneal fat/fascia ranged from 18% to 54% of the cases, along with a high percentage of overlap. Individual anatomic variations in the transversalis fascial analogs and the rectusial fascia varied from 7% to 84% of the cases. Thus overall incidence of the anatomic variations singly or in combination was 76.5% with respect to the 4 structures of primary outcome measure only, and 100% with respect to all the structures studied in the present work. The present observations confirmed that the total extraperitoneal preperitoneal (TEPP) approach for inguinal hernioplasty with the unhurried telescopic dissection provided an excellent perspective and opportunity not available with any other technique including the TAPP (trans-abdominal preperitoneal hernioplasty), and helped us in improving our accurate understanding of the xii
Abstract
abdomino-pelvic anatomy and markedly changed our overall perspective/ outlook after the study in many more aspects (Fig.2). As the seeing was the believing, the present study instilled a high degree of confidence in the surgical residents and peer colleagues to adopt the TEPP hernioplasty in order to exploit its proven advantages and benefits and to improve the quality patient care. Conclusions: The preperitoneal anatomy of the infra-umbilical and inguinal regions showed wide variations in the all the fascial layers studied,
with significant impact on the intra-operative
working as well as the post-operative clinical outcomes, indicating the paramount importance of their timely recognition and judicious surgical dissection of the complex fascial tissue planes of the groin in order to perform the TEPP hernioplasty with ease, rapidity and safety for the lasting cure and greatest patient satisfaction. Incidence of the individual variant anatomy in the 4 major structures studied, namely, posterior rectus sheath, arcuate line, transversalis fascia and preperitoneal fat/fascia ranged from 18% to 54% of the cases, along with a high percentage of overlap. Individual anatomic variations in the transversalis fascial analogs and the rectusial fascia varied from 7% to 84% of the cases. Thus overall incidence of the anatomic variations singly or in combination was 76.5% with respect to the 4 structures of primary outcome measure only, and 100% with respect to all the structures studied in the present work. The present study also discovered the presence of a double-layer preperitoneal fascia, internal spermatic fascia as an extension analog of the preperitoneal fascia, cord lipoma as an extension analog of the preperitoneal fat and a new structure of ‘rectusial fascia’ with the ‘retropubic fascia’ as its extension analog. In this area, there is a tremendous scope for future research with the use of newer laparoscopic approaches (Fig.3). More laparoscopic studies may help us in further stratification and easy understanding of the anatomic entities in order to eradicate the erroneous descriptions and interpretations from the literature. Utilization of pre-operative high definition ultrasonography, intra-operative high definition endovision, and modern energy sources like Harmonic scalpel/LigaSure for surgical dissection will prove a boon to enhance the precise knowledge of the preperitoneal anatomy among the practicing surgeons for the betterment of the quality patient care for the masses. Use of a virtual-reality digital learning and training programme for the surgical anatomy for the TEPP hernioplasty will be a worthy pursuit, strategic investment and rewarding exercise to materialize the fast-evolving concept of ‘Digital Surgical Skill Lab’ under a scientific anatomic model as the one proposed in the thesis.
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Abstract
Fig. 1: Present Study at a Glance
xiv
Abstract
Fig. 2: Outlook at a Glance
Fig. 3: Scope for Future Research xv
LIST OF TABLES S. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53
Fig. No. 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 4.29 4.30 4.31 4.32 4.33 4.34 4.35 4.36 4.37 4.38 4.39 4.40 4.41 4.42 4.43 4.44 4.45 4.46 4.47 4.48 4.49 4.50 4.51 5.1 5.2
Title of Table Age Distribution of Patients with Different Types of Posterior Rectus Sheath Extent Age Distribution of Patients with Various Morphologies of Posterior Rectus Sheath BMI Distribution of the Patients with Various Morphologies of Posterior Rectus Sheath BMI Distribution of Patients with Different Types of Posterior Rectus Sheath Extent Age Distribution of Patients with Various Subtypes of PRS: Morphology and Extent BMI Distribution of Patients with Various Subtypes of PRS: Morphology and Extent PRS Anatomy in the Consecutive Bilateral Inguinal Hernias Age of Patients with Mirror and Non-Mirror Anatomy of PRS and AL in Bilateral Hernias BMI of Patients with Mirror and Non-Mirror Anatomy of PRS and AL in Bilateral Hernias Age of Patients with Twin Variations of Extent & Morphology of PRS and AL BMI of Patients with Twin Variations of Extent & Morphology of PRS and AL Age Distribution of Patients with Various Subtypes of AL: Morphology and Extent BMI of Patients in different Subtypes of Arcuate Line (AL) Correlation of Arcuate Line with PRS Morphology Bilateral Anatomy of PRS and AL in Patients with Bilateral Hernia Levels of Arcuate Line With Respect to Different Landmarks U-AL Distance in Different Age Groups of Patients U-AL Distance in Patients with Normal Weight and Overweight/Obesity Age Distribution of Patients with Different Types of TF-SIR Body Mass Index (BMI) Distribution of Patients with Different Types of TF-SIR Distribution of TF-SIR among Different Workers Bilateral Anatomy of TF-SIR, TF-IR, PPF & EPF during the Consecutive Bilateral TEPP Age Distribution of Patients with Different Types of TF-IR Body Mass Index (BMI) Distribution of Patients with Different Types of TF-IR Distribution of TF-IR among the Different Workers undergoing TEPP Hernioplasty Bilateral Anatomy of SLEXT, ILEXT, IFL and MEXT during Bilateral TEPP Distribution of Corona Mortis in relation to Pectineal Fascia Bilateral Anatomy of IPT, P-Fascia, TA-Arch and R-Fascia during Bilateral TEPP Age Distribution of Patients with Different Types of Transversus Aponeurotic Arch BMI Distribution of Patients with Different Types of Transversus Aponeurotic Arch Age Distribution of Patients with Two Different Types of PPF in the Inguinal Region BMI Distribution of Patients with Different Types of PPF in Inguinal Region Age Distribution of Patients with Types of Preperitoneal Fat in Inguinal Region (EPF) Body Mass Index (BMI) Distribution of Patients with Different Types of EPF Distribution of Preperitoneal Fat in Patients with and without Cord Lipoma Age Distribution of Patients with Presence and Absence of Cord Lipoma Distribution of BMI of Patients with Presence and Absence of Cord Lipoma Effect of Demographics & Anatomical Variations on Endovision during TEPP Effect of Anatomical Variations on Endovision during TEPP Hernioplasty Effect of Demographic Characteristics & Anatomical Variations on EOP during TEPP Effect of Anatomical Variations on Ease of Procedure during TEPP Hernioplasty Effect of Demographics & Anatomical Variations on Operation Time during TEPP Effect of Anatomical Variations on Operation Time during TEPP Hernioplasty Effect of Demographics & Anatomical Variations on Peritoneal Injury during TEPP Effect of Anatomical Variations on Peritoneal Injury during TEPP Hernioplasty Effect of Demographic Characteristics & Anatomical Variations on Surgical Emphysema Effects of Anatomical Variations on Surgical Emphysema during TEPP Hernioplasty Effects of Demographics & Anatomical Variations on Postoperative Seroma Effect of Anatomical Variations on Postoperative Seroma after TEPP Hernioplasty Correlations (p-values) between Primary & Secondary Outcome Measures Correlations (p-values) between Primary & Secondary Outcome Measures Combined Correlations (p-values) between Primary & Secondary Outcome Measures Combined Correlations (p-values) between Primary & Secondary Outcome Measures
Page No. 79 80 84 85 86 87 90 91 92 92 94 96 97 98 99 99 101 101 105 106 106 107 108 109 111 115 116 120 122 123 128 128 132 133 135 136 137 149 154 159 161 170 173 178 180 181 185 187 190 199 100 249 250
LIST OF FIGURES S. No. 1. 2. 3. 4. 5. 6. 7. 8. ---9. 10. 11. 12. 13. 14. 15. ---16. 17. 18. 19. 20. 21. 22. 23 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48.
Figure No. 1.1 2.1A 2.1B 2.1C 2.2 2.3 2.4 2.5 ----2.6 2.7 2.8 2.9 2.10 2.11 2.12 -----2.13 3.1 3.2 3.3 3.4 3.5 3.6 3.7 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25
Title of Figure Bi-laminar aponeuroses of external oblique, internal oblique & transversus abdominis The anterior boundary of the inguinal canal The superior and inferior boundaries of the inguinal canal The posterior boundary of the inguinal canal Diagrammatic illustration showing the peritoneal folds and fossae Diagrammatic representation of the ‘Triangle of Doom’ in the right groin of the body Diagrammatic representation of the ‘Triangle of Pain’ in the right groin of the body Right Inguino-Pelvic Region: Diagrammatic illustration showing the ‘Triangle of Doom’ and the ‘Triangle of Pain’, the two forming the ‘Trapezoid of Disaster’, and the Corona Mortis Right Inguino-Pelvic Region: Diagrammatic representation of the arterial corona mortis (4-5) Right Inguino-Pelvic Region: diagrammatic representation of the ‘Dangerous Eye’ Right Inguino-Pelvic Region: Diagrammatic representation of Hesselbach’s Triangle (HT) Rectus Sheath Formation Above Umbilicus (Cross Sectional View) Rectus Sheath Formation Below Umbilicus (Cross Sectional View) Rectus Sheath Canal and retropubic space (Parasagittal section) Bi-laminar nature of the external oblique, internal oblique and transversus abdominis aponeuroses, and the tri-laminar formation of the anterior & posterior rectus sheath Arcuate Lines: Diagrammatic illustration redrawn from Monkhouse and Khalique (1986) Flow Chart of Surgical Technique Incision and Port Placement for TEPP Mesh Placement Completion of Left TEPP Early Interval Second Side TEPP Delayed Interval Second Side TEPP Flow Chart of the Clinical Research Methodology Age Distribution (decade-wise) of the patients undergoing TEPP hernioplasty (N = 60) Distribution of Occupations of patients undergoing TEPP hernioplasty (N = 60) Distribution of clinical types of inguinal hernias in patients undergoing TEPP hernioplasty Associated Hernias (A) An incomplete PRS (B) A sharp well-defined arcuate line (C) Arcuate line in complete PRS Complete posterior rectus sheath (C-PRS) Complete posterior rectus sheath (C-PRS) Thinned-out complete posterior rectus sheath (PRS-CTO) Right TEPP: Creation of an artificial arcuate line (AL) in the Double Layer PRS-CPT Correlation between the PRS-PT types and the PRS extent Whole-Tendinous Complete Posterior Rectus Sheath (C-PRS) Right TEPP: L-PRS with very low arcuate line (AL) & Creation of artificial arcuate line Distribution of Classical & 11 Variant Subtypes of PRS-Morphology Correlation between Posterior Rectus Sheath (PRS) Types and Occupation Double Arcuate Line (DAL) Distribution of the Arcuate Line (AL) Types in the Different Workers levels of Arcuate Lines with relative positions of their medial and lateral ends Right TEPP: Low Arcuate Line (arrow) crossing the Cooper’s ligament The positions of the arcuate line Correlation between Arcuate Line (AL) levels and Occupation The positions of the arcuate line and its lateral end Correlation between TF-SIR and Occupation Right TEPP: TF in the same patient as in the Fig. 4.9 Correlation of TF-IR Types with Patients’ Age (A), BMI (B) and Occupation (C) Correlation between TF-IR and the patients’ Occupation
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Page No. 4 14 14 14 24 28 29 30 ----30 34 34 37 38 38 39 -----48 65 68 69 69 70 70 72 75 75 76 76 79 81 81 82 83 88 88 89 92 92 95 97 100 101 101 103 104 107 108 109 111
S. No. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101.
Fig. No. 4.26 4.27 4.28 4.29 4.30 4.31 4.32 4.33 4.34 4.35 4.36 4.37 4.38 4.39 4.40 4.41 4.42 4.43 4.44 4.45 4.46 4.47 4.48 4.49 4.50 4.51 4.52 4.53 4.54 4.55 4.56 4.57 4.58 4.59 4.60 4.61 4.62 4.63 4.64 4.65 4.66 4.67 4.68 4.69 4.70 4.71 4.72 4.73 4.74 4.75 4.76 4.77 4.78
Title of Figure Right TEPP: Transversalis fascial sling (TFS) Correlation between the Transversalis Fascia Sling (TFS) and the Occupation Left TEPP (A) Left TEPP and (B) Right TEPP Correlation between MEXT (Medial Fascial Extension) and Occupation of the Patients Right TEPPs: Pectineal Fascia (PF) Correlation between Pectineal Fascia and Occupation of the Patients Right TEPP: A well-defined Iliopubic tract and very low transversus aponeurotic arch Right TEPP: IPT, thin attenuated iliopubic tract Correlation between the Ilio-Pubic Tract (IPT) and the Occupation of Patients Right TEPP: Very Low Transversus Aponeurotic Arch and Well-defined Iliopubic tract (A) Left TEPP for indirect inguinal hernia (B) Right TEPP for indirect inguinal hernia Correlation between Two Groups of Transversus Aponeurotic Arch and Occupation Correlation between Five Groups of Transversus Aponeurotic Arch and Occupation Left and Right TEPP Indirect Hernial Sac Dissection during Right TEPPs Right TEPPs: (A) showing a double membranous preperitoneal fascia (PPF-DM) Correlation between Preperitoneal Fascia (PPF) and Patients’ Occupation Correlation between the Types of PPF and the Amount of the EPF Right TEPPs: Parietalization of the cord structures Right TEPP: Well-defined preperitoneal fascia (PPF) Right TEPP: Preperitoneal Fat (EPF) Correlation between the Types of PPF and the Amount of the EPF Cord Lipomas Cord Lipoma Correlation Between Cord Lipoma and Amount of Preperitoneal Fat Correlation between Size of Cord Lipoma and Amount of Preperitoneal Fat (EPF) Correlation Between Occupation & Presence & Size of Cord Lipoma Correlation Between Presence of Cord Lipoma and Patients’ Occupation Rectusial Fascia (RF) during early part of TEPP dissection TEPP: Thin membranous rectusial fascia (RF) underneath rectus abdominis muscle Correlation Between Rectusial Fascia Anatomy and Patients’ Occupation Correlation Between Morphology of Posterior Rectus Sheath (PRS) and Arcuate Line Correlation Between Morphology of Posterior Rectus Sheath (PRS) & Preperitoneal Fat Correlation Between Partly Tendinous PRS and Transversalis Fascia in Inguinal Region Correlation Between Morphology of AL (Arcuate Line) and PRS (Posterior Rectus Sheath) Correlation between TF of Supra-Inguinal Region and TF of Inguinal Region Correlation between TF-SIR and Pectineal Fascia Correlation between TF-SIR and TFS as well as MEXT Correlation between TF-SIR and IPT and PPF Correlation between Transversalis Fascia of Inguinal Region (TF-IR) & Iliopubic Tract (IPT) Correlation between Transversalis Fascia of Inguinal Region (TF-IR) and Pectineal Fascia Correlation between Pectineal Fascia and Transversalis Fascia of Inguinal Region (TF-IR) Correlation between TF-SIR, TF-IR and Iliopubic Tract Correlation between Iliopubic Tract (IPT) and Pectineal Fascia (P-Fascia) Correlation Between Morphology of PRS and Preperitoneal Fat (EPF) Correlation between Endoscopic Vision and Occupation Correlation between the Ease of Procedure (EOP) and the Posterior Rectus Sheath (PRS) Correlation between Endovision and Types of PRS-PT (partly tendinous) Correlation between Endovision and Types of Arcuate Line (AL) Correlation between Endovision & Transversalis Fascia of Supra-Inguinal Region (TF-SIR) Correlation between the Endovision and Transversalis Fascia of Inguinal Region (TF-IR) Correlation between the Endovision and the Transversalis Fascia Sling (TFS)
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Page No. 112 113 114 115 116 117 118 118 119 119 121 121 122 123 125 126 127 127 129 129 130 131 133 134 134 135 136 137 138 139 139 140 141 141 142 142 143 143 143 144 144 145 145 146 147 147 148 150 151 151 152 152 155
S. No. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132. 133. 134. 135. 136. 137. 138. 139. 140. 141. 142. 143. 144. 145. 146. 147. 148. 149. 150. 151. 152. 153. 154.
Figure No. 4.79 4.80 4.81 4.82 4.83 4.84 4.85 4.86 4.87 4.88 4.89 4.90 4.91 4.92 4.93 4.94 4.95 4.96 4.97 4.98 4.99 4.100 4.101 4.102 4.103 4.104 4.105 4.106 4.107 4.108 4.109 4.110 4.111 4.112 4.113 4.114 4.115 4.116 4.117 4.118 4.119 ------4.120 ------4.121 4.122 4.123 4.124 4.125 4.126 4.127 4.128 4.129
Title of Figure Correlation between the Endovision and the Pectineal Fascia Correlation between the Endovision and the Iliopubic Tract Correlation between Endovision and Classical & Variant Anatomy Groups of TA-Arch Correlation between the Endovision and the 5 Groups of Anatomy of TA-Arch Correlation between the Endovision and the Preperitoneal Fascia (PPF) Correlation between the Ease of Procedure (EOP) and the Patients’ Occupation Correlation between the Ease of Procedure (EOP) & the Types of PRS Correlation between Ease of Procedure (EOP) and the Types of Arcuate Line (AL) Correlation between Ease of Procedure (EOP) and the TF-SIR Correlation between Ease of Procedure (EOP) and TF-IR Correlation between the Ease of Procedure (EOP) and Transversalis Fascia Sling (TFS) Correlation between the Ease of Procedure (EOP) and the Pectineal Fascia Correlation between the Ease of Procedure (EOP) and the Iliopubic Tract Correlation between Ease of Procedure (EOP) and Transversalis Fascial Sling (TFS) Correlation between Ease of Procedure (EOP) and Medial Fascial Extension (MEXT) Correlation between the Ease of Procedure (EOP) and the TA-Arch Correlation between the EOP and the 5 Groups of Anatomy of TA-Arch Correlation between the Ease of Procedure (EOP) and Preperitoneal Fascia (PPF) Correlation between Operation Time and the Patients’ Age, BMI & Occupation Correlation between the Operation Time (OT) & Posterior Rectus Sheath (PRS) Correlation between Operation Time (OT) and the Types of Arcuate Line (AL) Correlation between the Operation Time (OT) and TF-SIR and TF-IR Correlation between the Operation Time (OT) and the Preperitoneal Fascia (PPF) Correlation between the Operation Time (OT) and the Preperitoneal Fat (EPF) Correlation between the Peritoneal Injury (PI) and the Co-Morbidity. Correlation between the Peritoneal Injury (PI) and the Occupation of the Patients Correlation between Peritoneal Injury and the Classical/Variant Anatomy of AL Correlation between Peritoneal Injury (P. Injury) and Types of the Arcuate Line Correlation between the Surgical Emphysema and the Co-Morbidity Correlation between the Surgical Emphysema and the Occupation Correlation of incidence of surgical emphysema between the Classical & Variant PRS Correlation between incidence of surgical emphysema and 12 Types of PRS Correlation between incidence of surgical emphysema and Types of the PRS-PT Correlation between incidence of surgical emphysema and the TF-IR types Correlation between incidence of Postoperative Seroma & Side of Inguinal Hernia Correlation between incidence of Postoperative Seroma and Type of Inguinal Hernia Correlation between the incidence of the Postoperative Seroma and the Occupation Correlation between postoperative Seroma and Classical/ Variant Anatomy of TA-Arch Correlation between Seroma and the 5 Types of TA-Arch Correlation between the Port Site Infection and the Patients’ Occupation Correlations between the chronic inguinodynia and the Endovision (A), Ease of procedure (B), Operation Time (C), and Peritoneal Injury (D) Correlations between the chronic inguinodynia and the surgical emphysema (A), postoperative seroma (B), and port site infection (C) Correlation between the Endovision & the Ease of Procedure Correlations between Endovision and the Operation Time & Surgical Emphysema Correlations between Ease of Procedure and Operation Time & Surgical Emphysema Correlations between Peritoneal Injury and Ease of Procedure & Operation Time Correlation between patients’ BMI and the Secondary Outcome Measures Correlation between the Co-morbidity and the Secondary Outcome Measures Correlation between Clinical Hernia Types and the Secondary Outcome Measures Correlation between Clinical Hernia Types and the Secondary Outcome Measures Correlation between Hernia Operation (TEPP) and the Secondary Outcome Measures
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Page No. 155 155 156 156 157 157 160 160 162 162 163 164 164 165 165 166 166 167 168 171 171 174 174 175 176 176 177 179 182 182 182 183 183 184 186 196 188 188 188 189 191 ----192 ----193 193 194 194 195 196 196 197 197
S. No. 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 ---177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193
Figure No. 4.130 4.131 4.132 4.133 4.134 4.135 4.136 4.137 4.138 4.139 4.140 4.141 4.142 4.143 4.144 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 -----5.9 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 6.1 6.2 6.3 7.1 7.2 7.3 7.4
Title of Figure Correlation between the Extent of PRS and the Secondary Outcome Measures Correlation between the Morphology of PRS and the Secondary Outcome Measures Correlation between the Morphology of AL and the Secondary Outcome Measures Correlation between the Rectusial Fascia (RF) and the Secondary Outcome Measures Correlation between the TF-SIR and the Secondary Outcome Measures Correlation between the TF-IR and the Secondary Outcome Measures Correlation between Transversalis Fascial Sling and the Secondary Outcome Measures Correlation between Medial Fascial Extension and the Secondary Outcome Measures Correlation between Pectineal Fascia (PF) and the Secondary Outcome Measures Correlation between Iliopubic Tract (IPT) and the Secondary Outcome Measures Correlation between Transversus Aponeurotic Arch & Secondary Outcome Measures Correlation between Preperitoneal Fascia and the Secondary Outcome Measures Correlation between Preperitoneal Fat (EPF) and the Secondary Outcome Measures Correlation between Cord Lipoma and the Secondary Outcome Measures Present Study at a Glance Comparative Morphology of the Incomplete PRS: Ansari vs. Rizk Comparative Morphology of Incomplete PRS: Ansari vs. Loukas Comparative Morphology of the Complete PRS: Ansari vs. Rizk Comparative Distribution of Mirror & Non-Mirror Anatomy of the PRS Correlation Between the PRS Extent and the Endovision Correlation Between PRS Extent and EOP (ease of procedure) Correlation Between PRS Anatomy & Secondary Outcome Measures Diagrammatic Representation of 4 groups of Arcuate Line Levels and their Comparative Evaluation with those of Monkhouse and Khalique (1986) Correlation between the AL Anatomy and Secondary Outcome Measures A sharp well-defined Arcuate Line (arrow) with sign of light house (S) Diagrammatic representation of anterior wall of the Abdomino-Pelvic Area Diagrammatic representation of anterior wall of the Inguino-Pelvic Area Endovision in presence of Classical and Variant Anatomy of Inguinal Region Ease of Procedure in Presence of Classical & Variant Anatomy of Inguinal Structures Operation Time) in Presence of Classical & Variant Anatomy of Inguinal Structures Peritoneal Injury in Presence of Classical & Variant Anatomy of Inguinal Structures Surgical Emphysema in Presence of Classical & Variant Anatomy of Inguinal Structures Surgical Emphysema in Presence of Classical & Variant Anatomy of Inguinal Structures Present Study at a Glance Outlook At A Glance Scope for Future Research Diagrammatic illustration of Effective Rectus Sheath Canal (Parasagittal section) Outlook At A Glance Proposed Anatomic Model of Abdomino-Inguinal Region (Parasagittal section) Scope For Future Research
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